Lakhasly

hospital than at the tertiary hospital. Hence, the TB dispensaries should strengthen the improvement of medical technology, and the tertiary hospital should consider lower prices for medical services to improve doctor–patient trust. Additionally, the factor analysis showed that the measurements of the constructs displayed good reliability and validity, which provided a possible solution for the measurement of service quality and service satisfaction in future studies. The SEM exhibited good fit indexes, suggesting that our conceptual model was reasonable and had certain guiding value in rebuilding doctor–patient trust in practice.
In the present study, doctor–patient communication showed a significant, direct effect on doctor–patient trust (P = 0.016), with the highest total effect. Doctor–patient communication could be considered as the beginning of medical service delivery, which shapes the first impressions of both the doctor and patient. Additionally, effective doctor–patient communication helps to eliminate the psychological barriers and differences between doctors and patients, which all are beneficial to encouraging doctor–patient trust50,51. More importantly, medical service quality exerted the greatest direct effect on doctor–patient trust (b = 0.409, P < 0.001) in our study. Service quality is the core of any service industry and deserves the most attention, particularly in healthcare52,53. An improve- ment in medical service quality, namely, a safe and effective medical service, would increase the trust of patients in doctors and hospitals52. Moreover, consistent with the previous study, patient-perceived service satisfaction was another factor that predicted doctor–patient trust, but some studies have implied that patients were not very satisfied with the medical services in China19,54,55. Therefore, an urgent need is to improve patient satisfaction with medical services. Doctor–patient communication and medical service quality exerted significant positive effects on service satisfaction, providing solid evidence for methods to improve patient satisfaction in medical practice.
Furthermore, this study clarified the mediating relationship between doctor–patient communication, medi- cal service quality, service satisfaction, and the dependent variable doctor–patient trust. First, sufficient doc- tor–patient communication positively influenced doctor–patient trust mediated by medical service quality or service satisfaction. According to the traditional trust theory, the interaction or communication between indi- viduals is the starting point for the formation of all social structures, particularly interpersonal trust56,57. Com- munication between the doctor and patient is the prelude to medical delivery behaviour, in which the doctor and patient exchange information about the health check-up, diagnosis, treatment, prognosis, and other important information. Effective communication may improve the patient’s experience and perception, namely, patient- perceived service quality and satisfaction, of the medical service, which is beneficial to build the trust of patients towards doctors. Additionally, the medical service quality and service satisfaction are considered sequential mediators from doctor–patient communication to doctor–patient trust, a relationship that has not been con- firmed in previous studies. After careful consideration, this finding is logical, because effective doctor–patient communication enables medical staff to better understand the patient’s health service needs, to provide better services, and thus in turn to improve patient satisfaction with medical services, which is conducive to the estab- lishment of doctor–patient trust4,58.
Based on these findings, this study provided some implications for practice. Rebuilding of doctor–patient trust may be achieved by improving doctor–patient communication, medical service quality, and service satisfaction in the process of medical service delivery. First, doctor–patient communication skills must be strengthened, particularly the communication skills of doctors, which are still not very good in China4,59. An improvement in doctor–patient communication is conducive to the improvement of medical service quality and patient satisfac- tion, which are all beneficial to establishing patient trust in medical staff. The main method of doctor–patient communication in China is face-to-face communication, but the previous study reported similar for between screen-to-screen and face-to-face doctor–patient communication60; additionally, researchers have documented that a “Photo Stories” presentation contributes to doctor–patient communication61, which all provide evidence of future communication methods in China. Importantly, Chinese medical staff must develop their communica- tion skills, such as listening to patients, engaging them in shared decision making about health, and increasing awareness of performance-related feedback in medical practice62–64. Certainly, patients should also seriously
(2020) 10:21956 | https://doi.org/10.1038/s41598-020-78921-y 7 Vol.:(0123456789)

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adhere to individual literacy in health training, and with the participation of their families, they should alleviate their discomfort and vulnerability and feel open to express themselves65,66.
Moreover, the service quality, which is the foundation of the medical industry, should be improved in reality, which is not only reflected in the professional skills of medical staff but also reflected in their attitudes and basic behaviours in medical service delivery. Hospitals should establish a systematic medical training and learning system to ensure that medical personnel are able to constantly improve their professional talents and cultivate a sense of responsibility, which may decrease the occurrence of lower service quality, adverse events, and medical errors52,67. Additionally, the medical staff should be required to establish the “patient-centred” service concept, which embodies the respect and humanistic healthcare in the whole medical service process67. Doctors’ improper medical practices must also be monitored to provide patients with necessary medical services and products68. Crucially, service satisfaction plays a key role in building doctor–patient trust. Medical service satisfaction is always a concern in China, but it does not appear to have been substantially improved, even with the implementa- tion of the medical reforms in 200969. Therefore, service satisfaction should be viewed as a feedback index of the quality of medical service in future practice; on the other hand, service satisfaction should also be continuously measured and improved, which may contribute to the establishment of doctor–patient trust.
Nevertheless, several limitations need to be addressed in future studies. First, the sample analysed in this study was limited to participants from Dalian. This sample limits our ability to generalize findings to other regional groups. The problem of trust towards a doctor is not limited to patients with TB, and patients with other dis- eases also experience the same problem. Further studies should be extended to more diverse patients to test the adaptability of our research model. Second, the data were collected only through self-report measures, which might affect the results of this study. Patients with preferential treatment from the doctor may be more likely to provide positive feedback, which may account for reporting bias. Future studies could combine participants’ self-reported measures and content analyses by interviewing them to obtain their opinions and feedback from others. Finally, our findings were based on cross-sectional data, which limit our ability to draw a practical causal conclusion. Although the tested model provides one possible combination of the relationships, receiving more positive feedback might plausibly predict doctor–patient trust. Therefore, longitudinal studies are needed to examine causal or bi-directional relationships between these variables.